Wednesday, May 11, 2016

They come in
ambulances, they come in vans, and they come in crawling, drunken, and puking
in pans.

They come with strokes,
overdoses, injuries and pain.

They fall and get
fractures from ladders, and many other things that really don’t matter.

They demand the best,
the most, the quickest, for free - and yet, when needed, they can’t even pee.

They injure themselves in so many ways; too
many to count as there are not enough days.

It is sad really, the
condition of people - so grand a species, that finds everything so lethal.

They will not stop
coming, these humans with brains, they just need immediate relief of all of
their pains.

So in the end, there
really is nothing to do; drugs, seatbelts, gravity and rape, learn they will
not, these humans with brains; as we will patch them up good, send them back where
they stood, and wait for their return, for it is our livelihood.

An ED is a stressful place, quite different than any other
work environment, outside of, perhaps, active duty military, paramedics, and police. We, the
nurses, are stretched to accomplish all manner of tasks, in the quickest way,
without an error, with the least amount of cost, with the most skill, capturing
all of the data, with the fewest steps, and with an overwhelmingly cheery
demeanor – all day, all night, all year long.

Every second counts, but not only for patient care, speed of
service delivery, electronic chart manipulation, management benchmarks and
facility goals – but for time itself. Seconds add up to minutes, and minutes to
hours. It is the basis of all science. And so, every second lost to a missed
step, a mishandled medication, a broken printer, another trip with a patient to
the bathroom, is time compounded. Add to all of the thousands of tasks
performed in each 12-hour shift, another 2.8-second chart entry, another
software screen to navigate, another step in any process. Without taking away precious
seconds from another task, this will all end up lengthening the day.

The Massachusetts Institute of Technology (MIT) produced a
wonderful study of why traffic comes to a complete stop on the freeway for no
apparent reason. The results show that if any one vehicle even taps the brakes
for a half second, producing just a quick glow of the brake lights and a drop
in speed of an infinitesimal amount, that this action is carried on behind that
vehicle - each one driver lengthening the reaction until, one mile away, you
are at a standstill. Apply this to any task in a busy ED, such as a printer
that won’t function. Such a delay (the glow of a brake light) means you have to
re-print a document by altering the print options, checking for a signal,
checking the paper supply, changing the default location, etc. Eventually you
will walk to another room, or location, and try this same procedure with a
different terminal, and a different printer. This simple, yet overlooked delay,
has prolonged the medication administration for another patient by 2.4 minutes.
On the surface this time seems short, yet compounded with hundreds of others –
you are sitting in your stalled car, in gridlock, listening to death metal
pouring out of a nearby Pinto.

In addition to the thousands of tiny delays, is the fact
that no one person is responsible for eliminating or repairing these delays.
This magical fix-it person is actually – you. Yes, the nurse who is actively
engaged in the time delay is also the one responsible for finding a solution
for the problem. A repair can be something like signing into a ‘work order’
software program and navigating through various fields for hardware repair, resetting
all of the default printer preferences – or, worse yet, a time consuming
telephone call to some outsourced IT call center, to someone who has no
investment in your situation, and is not concerned about the passage of time in
any way.

A recent study from Michigan
State University in East Lansing, shows that on average, an interruption in a
task of only 2.8 seconds leads to a 15 minute delay in completing that task.
Think of how many times you have walked toward a patient room, only to be
diverted by a call light from another room, or the time you go to the
electronic medication dispenser, forget the patients name, and then have to go
find a computer, log in, and search. Compound all of these by 100 for a 12-hour
shift, and it is no wonder that the length of stay (LOS) is creeping up again.
As the complexity of a system grows, so does the potential for delays. And with
people only employed to add to the complexity, and not to streamline it, there
is no end in sight for the difficulties.

Concerning the hospital LOS, it
was decreasing ten years ago, and everyone was quite proud. But as the
population has grown and aged, rampant drug use has increased, care has become
intolerably expensive, and the computer systems that bind it all together have
become more fractured – the length of stay has risen.

Antoine de Saint-Exupery wrote,
“A designer knows he has achieved
perfection not when there is nothing left to add, but when there is nothing
left to take away”. Any experienced computer programmer in the medical
profession has this same St. Exupery ability; to create a streamlined
user-friendly platform that is modern, and simple, and attains the goals set
forth by the care. Think Amazon and Google – two of the worlds most
user-friendly and lucrative businesses on earth. They are simple to navigate,
never go down for upgrades, and are super efficient. If only charting an
intubation in the EMR was as simple as buying a vibrator on Amazon. Oh the
glory!

However, by a series of
unfortunate events, we the Emergency Department nurses (as well as the floor
nursing staff) have been burdened with an Electronic Medical Record (EMR) that
is nothing more than ten thousand loose parts flying in formation. I can stream
live color video from Saturn on my iPhone, and yet our $390 million dollar EMR cannot
spellcheck or convert pounds to kilograms, doesn’t know that penicillin is a
drug or an apple is a food. Every day within the EMR there is a tweak, or a
change, or a malfunction, or a discovery, all adding tiny little bits of time
to the day, all reverse-engineered at the sacrifice of timely patient care.

So, with time being finite, and
the fact that patient severity and volumes have increased - and with a limited
corporate budget, choke holds on staffing, and with the phrase ‘multi-tasking’
becoming the invisible phrase between each line of a mission statement –all of
these measurable factors are pushing quality to its edge.

A study published
in The Lancet in 2014 found that an increase in a nurse’s
workload by one patient increased the likelihood of a patient in that hospital
dying by 7 percent. Staffing ratios
also appear to reduce the rate of readmissions, many of which are preventable
and constitute a significant cost for hospitals. The Affordable Care Act (ACA)
sets penalties for hospitals with high rates of readmissions. In one 2013
study researchers at the University of Pennsylvania School of Nursing
examined data from hospitals across the U.S. and found that those with higher
staffing ratios had 25 percent lower odds of being penalized under the ACA for
excessive readmissions than ones with lower staffing ratios but otherwise
similar conditions.

Staffing ratios for the Emergency Department are generally
viewed upon as blasphemy by management. It tastes like freezer-burned brussel
sprouts to the well-educated palates of higher offices, and it also affects
corporate earnings and creates shareholder distain. So, even though the
evidence supports staffing ratios, it is not likely to occur anytime soon. So,
with an ever-increasing population of very ill humans, computerized charting
that bludgeons to death even the most digital savant, and an employing host
incapable of understanding the trials of its workers – the future is bleak my
friend.

Time is what is killing the nursing profession - or, to be
precise, the lack of time.

We have a nurse in our Emergency department, and I will call her
Grace. Every department has one - a
true to life, dyed in the wool, for real nurse. She holds patients hands,
believes their crazy stories, looks into their eyes, hugs them and cries with
them, even spends her own money on them. She walks them out to their car, she
thinks about them at night, she…cares. There is nothing in the electronic
record that reflects her care – nothing. There is no check box for ‘care’, or
‘concern’, or ‘love’. But, she is measured on the same scale as the rest of the
staff: 500 data points per trauma patient, LOS is too long, time to pain meds
is unacceptable, CMS benchmarks are insufficient, medication scanning is
sub-par, etc. Grace decided to use her time for patient care instead of bowing before the graven idols of statistical data
– and she will be punished for it. However, is this the nurse you want taking care
of your daughter or mother - or would you prefer the nurse that excels in
haste.

So how does good direct patient care look to the billers and
codes of a profitable organization? The more boxes checked, lines filled in,
tabs completed, tasks timed, and redundant research based data entered (all
timed to organizational and national benchmarks of speed) – the greater the
patient bill, the greater the reimbursement, the greater the ability to pay staff and procure
new technology. How does one code for Grace’s level care - you can’t. Nursing
has its flaws, but intelligence is not one of them. We all know that taking
care of the EMR, even with all of its defects, is better for the bottom line
than actual bedside care. The EMR makes money – bedside care does not.

A recent 3-year longitudinal study shows, “that nurses spend about
37% of their time with patients.
Work patterns were increasingly fragmented with rapid changes between tasks of
short length. Interruptions were modest but their substantial
over-representation among medication tasks raises potential safety concerns. There
was no evidence of an increase in team-based, multi-disciplinary care. Over
time nurses spent significantly less time talking with colleagues and more time
alone.” -Westbrook, Open Access.

Additionally,
a new study, published in April of 2016 by Johns Hopkins, is claiming that
complications from medical errors in hospitals are now the third leading cause
of death behind heart disease and cancer. This is a bold statement, and yet it
describes the environment where, being over tasked and understaffed, it is
almost anticipated. Various entities that hold great stakes in these findings –
particularly, the insurance companies, the government, and pharmaceutical
lobbyists - will dissect this study with vigor, most likely adding new forms to
the already fragmented EMR, adding steps for giving medications, perhaps even
an official “time out” with a co-worker as witness, before even a Tylenol can
be given. Again – time.

Many new nurses are overwhelmed at the ability to capture time,
divide it, and dole it out in safe increments, especially in an active almost
battlefield style atmosphere. Multi-tasking is a term that is pushed down the gullets
of bedside nurses by all of administration. It is a clichéd term, loosely
expressing the ‘apparent human ability to perform
more than one task, or activity, over a short period of time. Multitasking,
however, can result in time wasted due to humancontext switchingand apparently causing more errors due to insufficientattention’. I for one do not want my orthopedic
surgeon multi-tasking.

This relentless battle for time could be pushing nurses into new
directions; instead of hand-to-hand combat with tasks and time, why not join a
new legion - where time and direct patient care have been replaced by the
ability to create time itself. In 2015, the burgeoning field of nurse
informatics now has an average salary of just over $100,000. These are seasoned
nurses who have either ‘been there, done
that’, or are fresh out of school, intent on good money without the direct exposure
to the various illnesses and maladies of humans. Lets face it – informatics is
where the money is right now, not bedside nursing. These jobs, however, are as scarce
as Bigfoot sightings. But as technology slowly consumes almost all of a nurse’s
time, there will be many more openings in the informatics galaxy.

We, as nurses, have twelve hours to produce as much profit as we
can for the institution. We, as nurses, all know where our paychecks and
retirement plans come from, and we understand the inner workings of the
healthcare system and all of its governmental tentacles. We are the data entry
specialists. We have 720 chaotic minutes to produce 10-20 complete medical
records, documenting up to 250 items per patient encounter, in real time, with
good outcomes. We are not measured in care, but in speed. We are not measured
in interactions and conversations, but in volume of data points. We are only measured by the electronic medial
record. “If it wasn’t charted – it wasn’t done” is the maxim we live by. Medical
care is a huge business – huge! The amount we spend on health care every year has grown from
$75 billion in 1980 to nearly $500 billion today. If this rate continues, by
the year 2020, we will be spending 40 cents of every dollar we make on health
care.

So, there you have it. A finite amount of time for patient care,
defined by economics and computer programmers - with an infinite range of
potential challenges, defined by human nature and chaos. Emergency care could
be described as a fractal -an expanding wave of symmetrical duties; a spiral of
events in time, always compounding, never ending. Just like the ticking crocodile in Peter Pan, time is
following us all.

The only real
solution is to manage, as best we can, the time we are given - and hope for
reasonable, noble changes from above. Changes such as; single task, simplify,
create practical patient ratios, eliminate redundancy, hire adequate staff, hire
the correct staff, streamline documentation, employ shift based problem
solvers, use new technology only if it is beneficial, base care on quality not
quantity, compensate experience, take pride in effort, talk with each other,
and always do the right thing – the first time.

Monday, February 8, 2016

Seeing is Not Always
Believing

So, there are a few things you should know about what you
see in real life, about what you see on the monitor at home, and what you think you see on the monitor at home.
Because all of this “seeing” is going to result in a print – a colorful,
accurate, sharp, paper print – that you can hold in your hands, frame, and
quite possibly – sell.

Pingora Spire, Wind River Range - Wyoming

You are standing on boulder in the middle of a lake, with
the tripod so low that only a yoga instructor could comfortably look through
the viewfinder. Backing up is impossible, and lying down is even more so. Your
fingers are stupid with cold, and the whole time you are thinking, why is there so much metal on a camera? The
scene before you is fantastic, and the golden hour of dawn is slipping past
quickly – clouds moving around, sections of rock glowing pink and then falling
again into silhouette. You work quickly to compose the shot, stand up and
groan, and then start pushing the shutter release – each 15-second exposure
seeming like an eternity.

At this very moment you relax, it’s all up to the camera and
the lens now - you are the only witness to this crazy colorful landscape. For a
few minutes you watch and memorize the scene, the colors, the shadows – it is
beautiful. This is what we work for.

Once back home you scroll through the dull raw images,
looking for that one that pops out, the one that reminds you most of what it
was like standing there on that boulder, freezing. Eventually one image stands
above the rest, and it is moved into a raw processor, and then transferred into
Photoshop for fine-tuning.

Of course, your monitor is already calibrated, your image is
captured and presented in the correct color space, you have a dark grey
background on your desktop, you are sitting alone in a darkened room, and there
is no ambient light to alter the work. Simple enough, right? It is like the
total opposite of where you were for those 15-second exposures.

You adjust the overall white balance, attend to the green
hues in the shadows with some selective color balance, draw down the glaring
whites, make sure the shadows are not too deep so that they don’t appear black
on a physical print, concentrate on the sharpness, look for dust spots on the
sensor, erase the errant purple tent in the background. All of these processes
take some time, sometimes hours – and the longer it takes, the more you are
being fooled.

I know that once I get involved with an exciting image I
just can’t stop until I think it is at a finished state. So, an hour and a half
go by and I save the file as a finalized .TIF and compliment myself on the
finished image. I drink a toast on a job well done and then do some stuff that
doesn’t involve sitting in a chair, in the dark.

Wind River Range - Wyoming

However, when I open the file the next day or, God forbid,
look at the image that I hastily posted on my Facebook business site – it looks
horrible! The colors are all weird, there is a blue cast that I can’t explain,
the oranges are pale – what the hell happened?

Eye fatigue my friend, or more accurately – color fatigue. I
am sure there is a scientific ophthalmological term for this, but color fatigue
seems perfect to me. It’s like all the cones in your eyeballs just get tired or
lazy, “Yea, that’s green, whatever”
or, “Orange? Oh this nasty yellow is good
enough for now.” You have 7 million color cones in the very center of your
eyes’ retina, and its hard to image all of them just falling asleep at the
wheel when you are using them the most – but they do.

Each little cone has to transfer a chemical reaction into an
electrical impulse and then send it on to your brain. Each one of these
impulses takes a little bit of energy, and then the cone has to ‘recharge’, for
a lack of better term. We trichromates
(red, green, and blue cones) weren’t meant to sit and stare at the emissive
display of a computer screen for hours. Instead, we were designed to spot the lime
colored edible leaf, to avoid the vivid red tree frog, and to watch out for
anything with spots hiding in the grass. I believe that by staring at an image
for too long reduces or alters the colors that we see. And the longer you stare
– the more you are being fooled.

So, what have I learned? Never post an image to the public
for at least one day. Open the image the next day, in the same darkened
environment, and look at it again with some fresh cones. Nine times out of ten
you will be wondering what the hell you were smoking when you did the
post-processing the day before. Better yet, what I now do is take a break while
editing. So, about every 15 – 30 minutes, I just walk away. Go get coffee,
check for the mail, figure out why that sound of rushing water is coming out of
the kitchen. Just get away from the display for a little while.

When you come back from the break you also get a fresh sense
of your composition, the center of focus, and
the color. It’s like proofing print images – tweaking them until the output
color is just right.

Wind River Range - Wyoming

It seems like there are always elements that can alter the
way your print appears, many of which are out of your control; the color
temperature of lighting, the print paper, the surrounding wall color, the
refraction of glass, the yellowing of the human lens and cornea. However, at
least now you are aware of color fatigue, and know when to - just walk away.

Tuesday, December 22, 2015

When I first reviewed this pack, it was awesome. Great use
of space, intriguing design, it carried well, and for the first two years it
served me well; day hikes all over the mountains and deserts, flights to the
far corners of the earth, etc. But, up until my most recent trip to Nepal had I
ever worn it day in and day out, in cold temperatures, at altitude, and
sweating my ass off. In short, I don’t think I had ever carried it while hiking
hard for an extended amount of time.

So, deep in the Himalayas, on day three of our adventure, I
was unpleasantly surprised to find all of my lenses soaked with water, my
business cards destroyed, lens cloths wet – then frozen, and beads of water
everywhere. The zipper had been secured tightly; there were no holes, and no
rain or snow either.

“How could this be”, I thought. I closed the back panel,
which was steaming in the cold air with sweat from my back, and realized that
there must not be any waterproof coating on the nylon back panel. The
combination of heat and moisture drives the sweat right through the material as
a vapor, where, once inside the bag, it condenses into water droplets all over
everything. Even my old Arcteryx backpack is still totally waterproof after ten
years. This is so un-cool!

In the Maze, Canyonlands - Utah.

“What the hell!” were my first words. How could this be? It
is designed and advertised as a professional adventure pack, built to carry
thousands of dollars worth of camera gear into extreme environments. Clearly my
day trips had not been tough enough to test the material.How could a sheet of uncoated nylon slip into
the manufacturing process? I was, to say the least, bewildered – and pissed.

The rest of the trip I had to completely zip closed the
inside ICU panel, and then zip up the back panel -hardly an easy entry with
this extra step. Even with this additional measure, the inside got wet, as
sweat soaked through and condensed onto the inner nylon ICU fabric.

Fast forward – six weeks have passed since I have been home
from Nepal. I had to shoot images in New York City in November, but made sure
that I had contacted F-Stop prior to that for a return authorization number
(RMA) so that once home, I could ship the bag back under warranty. The bag was
shipped back on December 2nd.

Now it gets complicated.

The way I was locking my pack to a rock in Hawaii. The foam backpanel in question can be seen here.

The customer service phone number that is on the F-Stop
webpage is registered to Kent, Washington. The return for warranty address is
Saint Louis, Missouri. All of the 14 people who are able to answer a customer
service question are located in an un-named country in Europe. The company is
based, I believe, in the USA. According to customer service, there are no
phones at the F-Stop facility in Missouri, only a computer. There are no North
American faculty that has access to phone services – at least as far as I could
determine.

The customer service staff all state, in broken English,
that they can answer all question. And yet, have answers to none. The 2-second
time delay between speaking, and them actually hearing, results in each party
talking at the same time, with painful periods of silence in between. It is
maddening. What they really do is write down your question, or order, or
concern, and email it to the phoneless staff in the USA, wait for a reply, and
then forward that email to you. It is a call center. There are no people at
customer service that have any direct contact with the products they represent.

I spent a very frustrating week just trying to figure out if
they ever got my bag as a return, let alone talk with someone about the fabric
issue, design changes, and a possible replacement pack. I was so stoked about
this American company, I cannot tell you how many people I have promoted this
product too. Now, unless some miracle of customer service suddenly rains English
speaking knowledge down on my head, I think this is going to be a deal breaker.

One week later…

I called the mysterious European country again, and started
the inquiry process all over, for the third attempt. This time they assured me
that someone would call me back with information, and in fact, they did call me
back within ten minutes – and told me that they had made a mistake and someone
from North America would contact me. This new person sent me an email stating
that the camera pack was fine, was being sent back to me, and gave this
insightful morsel of help…

“One recommendation is the pack be treated with
a product such as Nikwax to protect against external moisture such as high
altitude condensation or accumulated sweat.”

So, with a 20-year warranty on this
camera pack, I am supposed to treat the foam back panel with some product from
REI so that it will remain waterproof?I
have been backpacking for 30 years, and have had backpacks from various outdoor
companies – North Face, Arcteryx, Black Diamond, Dana – and have never had the
sweat from my back go into the pack, because they are - built to be taken into the backcountry by sweating humans!

So, in the end – this pack failed the true test of
adventure; their customer service was a pitiful runner up to United Airlines,
and the warranty is purely imaginative. Again, I am so disappointed in the
service at this company - I so wanted them to shine above the rest, to prove an
American company could stand tall for product reliability, workmanship, and integrity,
but instead – just another outsourced, off-shore, phantom company without a human
soul to talk with.

Wednesday, May 27, 2015

I have been working on this book for perhaps ten years, and over the last six months, I printed a few copies and had eligible friends proof read them for errors - which there were a handful.

Now, I think it is finally ready to sell.

One thing I have learned about publishing books, no matter if it is a photo book or a trade paperback, publishing is very expensive, and you will NOT get rich doing it. As a matter of fact, you would still qualify for food stamps if you were making a living at this. Ink and paper are very expensive in this country, so without going to China, I have accepted the fact that this book was written for pleasure - not profit.

Everyone asks what the book is about - and I still can't answer them swiftly. A friend recently read it, and for her it meant so much more than I had imagined. It spoke to her heart. For me, it is a tale of travel and adventure, and of finding your way in todays crazy world.

Wednesday, November 26, 2014

Emergency nursing is a battle, and the enemy is illness and
injury: automobiles, motorcycles, guns, cancer, obesity, suicidality, violence,
heroin, amphetamines, and narcotics. The
enemy never sleeps – and neither do the nurses in the trenches.

Each shift we see unspeakable harms; babies, children, men
and women, preyed upon by our own species, serious injuries incurred by the
technologies of man, and predation by unseen viruses – mutating, hiding,
eating. Our academic training falls far short of the reality of it all. It
dwells in the archaic principles of a bygone age of nursing; an age of divine
care and heroic selflessness - an age before antibiotics, before MRI, before
genome sequencing, before daVinci surgical robotics, cost centers, ICD coding,
case management, and the cats cradle of legal bondage.Academically, we do not produce nurses for
this kind of battle – they are seasoned in the field, in the trenches with the
enemy – and they either fail after only a few years, or become ED veterans,
legends of tenacity, inkwells of black humor.

Your only allies are your comrades. You are part of a crazy
dysfunctional family of misfits, somehow brought together by adventure, a sound
background in herding cats, and the unwavering ability to withstand the abuses
of mental and physical pressure. There is no personal space, and sometimes you
are cheek-to-cheek to complete a task. Through human sickness, you are all
bound together by touch, and smell, and sight. You know your friends by the
scent of their shampoo or the boniness of their elbows. We engage in bizarre
sudden games of Twister, putting our arms and legs all this way and that, often
times holding down flailing screaming nakedness, or cleaning diarrhea from an
anguished soul, their minds murky with Alzheimer’s. We cry over a dead baby,
and then bring a demanding meth addict his pain medicine, apologizing profusely
for the delay, hoping they won’t file a complaint over their slow service. We can
sense the seriousness of a patient’s condition by the eyes of our coworkers -
no words needed - only that look.
These trench warfare nurses are more than just office mates – they are deeply bound
together from being elbow-deep in atrocities.

There is also a sixth sense that develops over time – one
where you see dead people - although they don’t know it yet. It’s an unnerving
feeling, to know the future of certain patients, to see the walking dead - and
its even more unnerving to know that, short of a miracle, you will soon be
pumping their bodies full of semi-toxic drugs, pumping their chests with
battery operated machines, covering their brains with gauze. This sense grows
more powerful with time – and as it grows, you accept it as a grace, for with
it comes the ability to prepare for the worse, to stay a step ahead of the
downward spiral, perhaps even to alter the course of fate.

Experiences are drawn from an endless pool of suffering and
the complex machinery of the human frame that is its host. Terminal injury
aside, your shift in the trench is made up of a relentless flow of strangers -
strangers who want something. Some are legitimate in their request – to repair
their fractured femur, to breathe, to once again speak and move the right side
of their bodies so that they can tell their family how much they love them –
but many are not, and it is this complex set of customers that bring theater to
the Emergency Department.We, the
nurses, are on stage – and we are the primary actors. It’s an art really, to be
able to go from room to room and change your performance to fit the scene, to
get the job done, to be so convincing. This constant play, however, requires a
tremendous amount of emotion, and only with great effort can it be played out
for the entire twelve hours.

Compassion is a finite emotion. You can run out of it – and
once it’s gone, you hope the shift has ended. Strangely enough, it seems to regenerate. Once
your car leaves the parking lot and is pointed toward home, the day starts to
fade. The images, scenarios, little victories and disappointments, things that
no one outside the theater would ever understand – they all just wither as you
drive home to your family, a friend, a dog, or a good glass of wine. By the
next shift, your compassion meter seems to be back within operating range. ER
trench nurses dole out compassion carefully; it is a need-based commodity, and
a very valuable one at that. Once the words fucker
or cunt are directed at you a few
times in as many hours, you know very quickly who gets the compassion, and who
might not. Empathy – we have loads of that, its part of becoming a great actor
on the Emergency stage, to step into the shoes of our patients, to know what
they feel and want, and to change our language and bodies to deal with their
needs. Compassion though – that is precious.

Human interaction is a complex thing - even more so when
you, the nurse, are guided in your speech by the haunting cloud of legal gloom
that hangs over each of your words. Some patients have a known future, a
certain future that you can predict from your thousands of previous
experiences. However, you are compelled to avoid the truth, to keep your thoughts
and knowledge at bay, you skirt the fact that no matter how much money is
consumed by the institution, their loved one is going to die. Instead, you lie
– or, better yet, remain silent. Oh yes, a miracle might be conjured, but
probably not. You remain silent because people don’t want to hear it – that
their weight is the cause of their medical problems, that their smoking caused
their chronic back pain, that their addiction was the reason they pulled their
own eyes out. Truth is clean, but brutal - and we know it could result in an
unsatisfied customer, reduced reimbursement, a chain of migraines for the
managers, and possible termination. The truth could leave you without a job.
It’s frustrating for sure – but these harsh realities will also wither on the
drive home, slowly shaping a shell of invulnerability - every so slowly.

Dealing with these concerns is not taught in school – it
comes from experience, from thousands of mistakes made, and the learned ability
to repair a mistake. It comes from stories told by your comrades in the trench
– both of success and failure. You drink in the wisdom and knowledge of their startling
tales, add them to your own, slowly building an empire of knowledge. Emergency
nursing is both science and art, and from science comes known facts – kidney
functions, ejection fractions, clotting cascades, neural pathways, and ligament
insertions – but from art comes the soul of nursing. The ER is a sweeping
pallet of colors, and with time, you begin to mix the colors together, blending,
learning, discovering, sometimes having to start over, but in the end,
hopefully leaving each shift with numerous finished paintings. None will be
masterpieces – but perhaps one will be worth framing.

Nursing theory, nursing statistics, research, history,
models of care, concepts of nursing, community nursing (collectively known as jumping throughhoops, by some) – these are great course for those yearning for
work as directors and educators, but for those who desire direct patient care
in austere venues, all encompassing hard science and live preceptorship seems
the most logical path. Experience is understood as knowledge gained by repeated trials, and without a series of
supervised trials, experience will be slow to foster, frustrating, overwhelming,
and potentially dangerous. Under real world conditions, we perform tasks over
and over, perfecting each step, understanding the reason for each move, until
the task is performed efficiently, and
with an elegance of purpose. We work closely with each other, double-checking
our work, transferring our knowledge up and down a mental conduit, a hierarchy
of skills and experiences. ER nurses work on common sense, street smarts,
evidence-based science, protocols, and past knowledge – not a modified Roy
model.

No theoretical
lecture will present you with the truth of the battle – that at any moment you
could have your gloved fingers in a struggling vagina, and ten minutes later
you would be eating a slice of pizza; that you will become a master of urine
concentration, that the nauseating need for diarrhea will pass, and that the
three meals a day of peanut butter and graham crackers are all you really need
anyway. Some of your patients will hate you, and tell you so every time you
give them a meal tray. Some of your patients will love you, want to touch your
hair, ask about your family. Everyone you see driving a car will be a potential
murderer, high on crack, to be watched and avoided, the children in your car
more valuable than anything in your life. The constant coughing of aerosolized infection
will drift into your open mouth – and your immune system will strengthen,
becoming impenetrable, like the amour plating of a panzer tank – and you’ll
wish that just once in a while you could
get sick.

The fellowship of
nurses in the Emergency department is a coalition of shared sorrows and
triumphs, of near death experiences and close calls, of comedic interactions,
violent brawls, blood, urine, and vomit. It’s a place of chaos; old men dying
and babies being born, of wailing and sobbing, and of laughter. We crave the ability to produce a lasting
contribution, but are often times tethered by the very profession we live. We
work in the muck, on the front line – feeling quite alone, standing apart from
the greater architecture that is the hospital, nervous, but so alive. Every day
we see the insides of people, splayed open or draining, but always in awe of a
creation that is beyond one’s understanding. Goodness and evil live in curious
harmony within the ED, fighting it out as we try our best to feed the goodness,
starve the evil, and not be taken down in the process.

And yet, every once
in a while, when it’s dark and the beds are strangely empty, the trench nurses
creep outside and lean against the wintery walls of the building, each feeling
the heat from the others shoulders – and silently watch the snow come down - like
swirling stars, trapped within invisible cones under the lights of the parking
lot.

My friends who work at normal jobs always ask me why I stay.
And always, after a pause, I say,“How
could I leave now?”

About Me

I travel as much as I can afford, and afford much less than I desire. The rewards, however, are priceless.Watching sunlight creep across a red desert valley, glitter through an emerald forest, or transform a desolate expanse of ice and snow into a wrinkled lavender blanket is much more than these photographs can provide. They are simply tiny slices of time, a memory; a single moment of the landscape that will never be the same again.